Sleep Disorders in the DSM-5

Insomnia Disorder

Insomnia is the most common sleep disorder and is what most people think of when they hear about sleep problems. Insomnia involves difficulty falling asleep and staying asleep, and those with insomnia often report issues functioning during the day. 40 to 50% of those with insomnia have another mental disorder as well. Although insomnia may occur on its own, it can also be the result of a situational life event or circumstance.

Although many people have trouble sleeping every now and then, to be diagnosed with insomnia, the struggle needs to be consistent. To be diagnosed, the sleep disturbances need to happen at least three nights a week for at least three months. Along with this, they must result in a high level of distress or cause issues with daily functioning at work, school, or in other essential areas of life. To be diagnosed, a doctor must determine that the symptoms aren’t the cause of a medication or another condition.

Insomnia symptoms may be:

●      Recurrent: the patient has two or more episodes of insomnia per year

●      Episodic: symptoms of insomnia lasting one to three months

●      Persistent: insomnia symptoms last three months or longer

There are a number of different treatment routes that physicians may take when working with a patient who suffers from insomnia. The first thing to try is implementing good sleep hygiene techniques, which involve methods like optimizing your bedroom for sleep and creating a consistent sleep schedule. If sleep disturbances continue despite healthy sleep habits, physicians may prescribe medication or recommend therapy.

Physicians often treat chronic insomnia with both medications and behavioral techniques like cognitive behavior therapy. Over-the-counter medications like melatonin or CBD sleep gummies may be useful as well. Relaxation techniques like mindfulness, acupuncture, and massage therapy are also helpful in some patients with insomnia.

Breathing-Related Sleep Disorders

Obstructive Sleep Apnea

There are a number of sleep disorders related to breathing, the most common being sleep apnea. Obstructive sleep apnea is characterized by disturbances in breathing during sleep. Throughout the night, someone with sleep apnea will have moments of airway obstruction, which manifest as snoring, pauses in breathing, snorting, and gasping. These disturbances cause tiredness, fatigue, and low energy levels during the day.

Sleep apnea is most common in older adults, affecting 20% of this age group. Risk factors of sleep apnea include a family history of the disorder, being male, and being obese. To treat this sleep disorder, physicians may recommend lifestyle changes like weight loss or changing sleeping positions. Some patients may be prescribed a CPAP device, which keeps airways open during sleep. Some people experience increased stress or anxiety when using a CPAP, which can be significantly decreased through the use of cognitive behavioral therapy and exposure therapy.

Central Sleep Apnea

A rare type of sleep apnea is central sleep apnea, which is when the breathing disturbance happens as a result of the brain. In central sleep apnea, the brain doesn’t send the correct signals to the body, causing the patient to periodically stop breathing throughout the night. One can be diagnosed with central sleep apnea if he or she has five or more breathing pauses in an hour of sleep.

Sleep-related Hypoventilation

This sleep disorder involves periodic shallow breathing, high carbon dioxide levels, and low oxygen levels during sleep. Those with sleep-related hypoventilation often struggle with insomnia and low daytime energy levels as well. Risk factors for this difficult sleep disorder include substance use, use of certain medications, and the existence of medical conditions like chronic obstructive pulmonary disease, obesity and hypothyroidism.

Non-Rapid Eye Movement (NREM) Sleep Arousal Disorders

Non-Rapid Eye Movement or NREM sleep arousal disorders are characterized by episodes of awakening partially from sleep and then sleepwalking or having sleep terrors. These episodes can be scary and distressing, and they cause difficulty functioning in daily life. Those who sleepwalk walk around while asleep and are very difficult to wake up. Sleep terrors, also known as night terrors, involve waking up suddenly with feelings of extreme fear and physical manifestations of this, like sweating and a fast heart rate. NREM sleep arousal disorders happen most frequently in children and are less common with age.

Rapid Eye Movement (REM) Sleep Behavior Disorder

Rapid eye movement or REM sleep behavior disorder is characterized by periodic arousal during sleep, including speaking or movement. These moments are typically in response to a dream, for instance yelling when a distressing moment occurs in the dream. The speech is usually loud and emotional, and the movement can be sudden and dramatic, such as running or kicking. The behaviors present in REM sleep behavior disorder happen during REM sleep, usually at least 90 minutes after going to sleep.

This sleep disorder causes extreme distress and results in difficulty functioning. It also has social implications, as it can cause problems with one’s bed partner. The sudden movements may cause injury in the patient or his or her bed partner. REM sleep behavior disorder is uncommon, affecting under 1% of the population. It’s most prevalent in males over the age of 50.

Nightmare Disorder

As its name suggests, nightmare disorder involves long, scary nightmares that the dreamer remembers in detail after waking up. These nightmares are often elaborate epics that feel vivid and real, resulting in strong feelings of fear or distress. Nightmare disorder causes difficulty functioning in daily life. This sleep disorder is most common in late adolescence and early adulthood.

Hypersomnolence Disorder

Hypersomnolence disorder involves extreme sleepiness despite getting 7 or more hours of sleep. Those with this sleep disorder will often fall asleep unintentionally during the day. Hypersomnolence also involves sleepiness and difficulty waking up fully after waking up from a night of sleep. To be diagnosed, the patient needs to experience extreme sleepiness at least three times a week for three months or longer. Hypersomnolence causes distress and difficulty in functioning, affecting memory and the ability to focus. This sleep disorder usually starts in late adolescence or early adulthood.

Narcolepsy

Although many people associate sleep disorders with difficulty falling asleep, those with narcolepsy have the opposite problem. People with narcolepsy have an uncontrollable need to sleep during the day, causing them to fall asleep throughout the day multiple times. To be diagnosed, these episodes of sleep have to happen at least three times a week, though most patients with narcolepsy experience them daily. Narcolepsy also often includes episodes of cataplexy, which is a sudden loss of muscle tone caused by laughter or strong emotions.

Narcolepsy is often caused by low levels of hypocretin or orexin, a brain chemical that maintains wakefulness. Narcolepsy is a very rare sleep disorder, affecting only 0.02-0.04% of the population. This disorder most often starts in childhood, adolescence, or young adults.

Restless Legs Syndrome

Restless legs syndrome is a sleep disorder characterized by the irresistible need to move one’s legs, a feeling that often comes along with uncomfortable sensations like crawling, tingling, burning, or itching. This strong urge to move one’s legs happens during periods of inactivity, is relieved by movement, and primarily occurs only in the evening or night. Restless legs syndrome makes it difficult to fall asleep and often wakes the individual up during the night.

To be diagnosed, the patient must experience this urge at least three times a week for three months or more. Along with this, the symptoms must cause extreme distress or difficulty functioning, for instance resulting in low energy levels during the day. Restless legs syndrome is most prevalent in adolescents and young adults, and it affects 2-7% of the population.

Circadian Rhythm Sleep-Wake Disorders

In circadian rhythm sleep-wake disorders, the individual’s internal body clock becomes misaligned with the external state of darkness/light, causing the patient to feel extreme sleepiness during the day and wakefulness during the night. This causes a large amount of distress and difficulty functioning.

Circadian rhythm disorders may be caused by circumstances like working the night shift or going to bed at irregular times, or they can be caused by internal factors. Going to sleep and rising earlier than the cycle of nightfall and daybreak is most common in older adults, while having a delayed sleep cycle is most prevalent in adolescence.

Substance or Medication Induced Sleep Disorder

This sleep disorder involves disturbance to sleeping patterns or quality that is caused by a substance. The substance causing the disturbance may be a medication, alcohol, drugs, caffeine, or another substance, and the patient may be using it or abusing it. The four types of substance or medication induced sleep disorder are:

●      Insomnia: the individual has trouble falling or staying asleep

●      Daytime sleepiness: the individual has sleepiness, fatigue, and low energy levels during the day

●      Parasomnia: the patient experiences sleepwalking, night terrors, or nightmares

●      Mixed: the patient has a combination of these disturbances

This type of sleep disorder causes significant distress and difficulty functioning. Physicians may determine the best treatment route depending on the patient and the circumstances around the substance causing the sleep disturbances.